Basic Information
Provider Information | |||||||||
NPI: | 1205813318 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | COOK | ||||||||
FirstName: | MARSHALL | ||||||||
MiddleName: | LEWIS | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | COOK | ||||||||
OtherFirstName: | MARK | ||||||||
OtherMiddleName: | LEWIS | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 649 | ||||||||
Address2: |   | ||||||||
City: | FORT DEFIANCE | ||||||||
State: | AZ | ||||||||
PostalCode: | 865040649 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9287298000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | CORNER OF ROUTE N12 AND N7 | ||||||||
Address2: |   | ||||||||
City: | FORT DEFIANCE | ||||||||
State: | AZ | ||||||||
PostalCode: | 865040649 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9287298000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/29/2005 | ||||||||
LastUpdateDate: | 03/17/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/04/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0005X | AZ19360 | AZ | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 207X00000X | 19360 | AZ | Y |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
No ID Information.